PNEC 2019

Predictors of Wound

Healing: Direct Angiosome

Perfusion vs. WIfIChristopher J. Abularrage, MD, DFSVS, FACSThe Bertram M. Bernheim Associate Professor of Surgery

Division of Vascular Surgery and Endovascular Therapy

The Johns Hopkins Hospital

DISCLOSUREChristopher J. Abularrage, MD

• No relevant financial relationship reported

Diabetic PADAngiosomes

• Angiosomes

• Concept defined by Ian Taylor in 1987

• Divides body into 3D anatomic units supplied by specific arteries

• Five units of the foot

Case #111/2015

• 61 year old

• PMH: DM, ESRD, CABG

• PSH: Left BKA (5/14), Right TMA (6/14),

• Right heel ulcer (7/14); Failed Apligraf

• Right SFA stent & Pop→AT stent

• Right lateral malleolar ulcer (7/15)

• ISR s/p repeat POBA (8/15)

• Failure to improve, recommended BKA

Case #1Bone scan + osteo calcaneus and fibula

PVR’s pulsatile

Right heel Right lateral malleolus

Case #112/2015 S/p debridement and fibular Integra

Right heel Right lateral malleolus

Case #11/2016 Failure of fibular Integra

Right heel Right lateral malleolus

Case #11/2016 Angio

Case #11/2016 Angio

Case #11/2016

• Vein mapping excellent

• Stress Test→ +reversible ischemia

• Cardiac Cath→ Unreconstructable

disease distal to patent grafts

• Trial of HBO

Case #12/2016

Right heel Right lateral malleolus

Case #12/2016

4mm POBAPre

Case #13/2016 S/p Heel STSG & fibular Integra

Right heel Right lateral malleolus

Case #16/2016 S/p Heel STSG & fibular Integra

Right heel Right lateral malleolus

Case #18/2016

Right lateral malleolus

Case #18/2016 (6mo s/p TP Trunk POBA)

4mm

PredilBuddy wire

4x38mm DES

Case #18/2016

Completion Angio

Case #114 mo after initial presentation

9/2016 1/2017

Diabetic PADAngiosomes

• 121 direct vs. 129 indirect limbs

• All endovascular interventions

Diabetic PADAngiosomes

P<.001

Soderstrom M et al. J Vasc Surg. 2013;57:427-35

Propensity Score

Analysis

1. Adjusted for pre-tx

variables

2. In-line revascHR 1.97, 95%CI 1.34-2.90;

P=.001

Conclusion

Endo adequate if inline

flow acheived

Definitions

• Direct Perfusion/Revascularization

• Open line from aorta to the artery supplying the wound angiosome (Lida)

• Heel and forefoot are PT (Alexandrescu)

• The angiosome artery revascularizedmatches that of the foot loss (Attinger)

• Little consensus when wounds span more than one angiosome

Open vs. Endo

What about the wound?

The WIfI Classification

The WIfI ClassificationValidation

The WIfI Classification

Definitions

• Compare predictive ability of WIfI classification vs

direct angiosome perfusion for wound healing

• Direct Angiosome Perfusion

– Any artery supplying the angiosome was patent or

revascularized

• Pedal arch patency (Rutherford)

– 0: Widely patent with retrograde flow

– 1: Widely patent without retrograde flow

– 2: Diseased or partially occluded pedal arch

– 3: Little or no pedal arch

Primary Outcome

• Wound Healing at one year

• Management

– Angiography with intent to perform

revascularization, preferentially direct

– Perfusion optimized if no direct options

– Debridement, local wound care, minor amputation

Study Cohort

99 Patients

225 Wounds

• Mean age 63 years

• 62.6% male

• Hypertension 87.9%

• Dyslipidemia 65.7%

• Tobacco Use 54.5%

• Hgb A1c 8.4%

• Insulin 56.6%

Wound Characteristics

May 25, 2019 72

Results

Results

P<.001

P=.89

Results

Results: Subanalysis

76

Conclusion

• More severe WIfI wounds were 23% less

likely to heal at 1 year.

• While direct angiosome perfusion was not

related to wound healing, it may be important

for higher WIfI stage wounds.

• WIfI classification has broad applicability.

• WIfI stage should be standard inclusion in all

future angiosome studies.

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